Saturday, December 31, 2011

All writing is communication. Creative writing is revelation. It is Self escaping into the Open.

E.B. White (1899-1985), The Elements of Style, 1974

December 31, 2011- It’s here at last – Goodbye 2011! Hello 2012!

What will be the big news in 2012? It will be venture capitalists, entrepreneurs, and consumers escaping into the Open by supplying new services to self-reliant individual consumers.

Why?

Think about it. The U.S. is a consumer-based economy. There are 310 million consumers, versus 500 hospitals, 1500 or so health plans, perhaps 900,000 doctors, 5 million other health care profesionals, and maybe 10,000 healthcare supply chain companies.

Think some more. The Internet has converted consumers into self-reliant individuals looking for free information on health care at the best price and advising each other through social media how to best find and use that information.

Think again. Markets are gravitating from brick and mortar to online, from inside hospitals and doctors’ offices to outside sites, from corporate sites to individual sites, from institutional care to self-care, particularly care administrated, orchestrated, and applied in homes, by consumers themselves rather than health care professionals. The U.S. is decentralizing from group, authority, and institutional decision-making to individual decision-making on a massive scale.

These consumer-based revelations have not escaped the attention of venture–capitalists, who are in the business of capitalizing on massive consumer-based social and commercial trends – such as Facebook, Twitter, Google, Skype, Kindle, and, of course, IPad, IPod, an IPhone, with “I” standing for either "I"nformation or "I"ndividuals.

That said, here are a few of my favorites.

• Instant Medical History – This clinical software allows patients to enter their demographics, chief complaints, symptons and history from their home computer or a laptop in the reception room before entering the exam room. Shortening the otherwise tedious history taking process.

• Emmi Solutions – The Chicago-based company preaches and practices “patient-engagement” by allowing patients to preview all aspects via videos of a procedure they are about to undergo or the consequences of a health problem they may have.

• Practice Fusion – This San Francisco EHR company has changed the EHR revenue model by having advertisers, not physicians. pay for installation, functioning through “Cloud” browsers rather than office-based systems, and meeting “meaningful use” CMS criteria, thus allowing physicians to have a “free” and “user-friendly” EHR.

• All those companies and start-ups who permit self-reliant consumers to test on their own for pregnancy, lipid levels, other blood content measurements, blood pressure fluctuations, weight gain or loss, and telemonitoring and audiovisual monitoring of patient appearances, vital signs, heart rhythms, unexpected complications, and other body functions.

Tweet:In 2012, Smart venture capitalists will support entrepreneurs and start-ups catering to and empowering health and disease-conscious consumers.

Friday, December 30, 2011

There is a land of the living and a land of the dead, and the bridge is love - the only survival – the only meaning.

Thorton Wilder (1897-1975), The Bridge of San Luis Ray (1927)

December 30, 2011- I knew a surgeon, John Najarian of the University of Minnesota, who did organ transplants. “Dick, “ he said to me, “I never knew a patient who didn’t want to live another day.”

To patients, in other words, medical care is all about survival

I thought of John as I read an article in today’s New England Journal of Medicine entitled “The Savings Illusion - Why Quality Improvement Fails to Deliver Bottom-Line Results.” Its four authors, from the Dartmouth Institute for Health Policy and Clinical Practice, maintain quality care rarely saves money because of structure of medicine is designed to save lives.

That’s what we doctors are here for – we love to save lives, and that’s what patients want – they would love to live another day.

I did not completely follow the logic of the Dartmouth people until Stuart Gitlow,M.D., writing in an AMA website “Take Back the Professional Advisory Group,” explained it to me. The Advisory Group, a provision of Obamacare, is designed to have the last word on lowering doctor pay, and Congress cannot override its decision.

Doctor Gitlow’s decision is simple – and profound.

Everybody wants to survive another day – at any costs. Sink or swim, live or die, and survive or perish- when it comes to living or dying- money is no object.

Here is Doctor Gitlow’s explanation.

“What these authors ignore is that the expected healthcare cost is infinite. That is, humans have one priority that outweighs all others - survival. Survival is more important than housing or eating. And survival in later years can be achieved only at increased cost.

Housing does not have an infinite cost - there is a basic need for shelter which can be met inexpensively. Food does not have an infinite cost - there is a maximum food intake for any one individual. Survival, on the other hand, not only can cost as much as one is willing to spend, but we want to spend as much as possible so as to live as long as possible in as healthy a manner as possible.”

“If I have $1000 to spend, and I can choose to spend $500 on my house and $500 on my food, but I'm dead, that was poor planning. I'd much rather spend $1000 on healthcare and live in a shelter eating table scraps. “

“The goal of any one person is, therefore, NOT to reduce healthcare costs but rather to increase them.”

“Each time I hear that healthcare costs are taking a larger percentage of each dollar spent, I am pleased, for it is certainly my perspective that the bulk of my future expenses should go toward my survival and my family's survival.”

“One day, perhaps this will change. Perhaps we will discover the gene/s responsible for aging of cells, and determine a method of turning aging off. I wonder how we might approach that fork in the road for then the equation would change - healthcare would be inexpensive but the supply of people would be infinite. Other factors would then become limiting.”

Tweet:The goal of doctors and patients is not to reduce health care costs, it is to survive.

Thursday, December 29, 2011

The most reliable way to forecast the future is to try to understand the present.

John Naisbitt

Weather forecast for tonight: dark.

George Carlin

December 29, 2011 - Here we are at the end of the year. It is time for my annual health care forecast.

• One, it all depends on the election - If we have a Democratic President and Congress, it’s Obamacare, full-speed ahead. If Obama wins and has a Republican Senate, it’s slow go – with reduced funding and slow implementation. If its Republican government at all levels, it’s Obamacare repeal and time for alternative plan.

• Two, it depends on the June Supreme Court announcement of its decision on the individual mandate, the whole plan, and Medicaid implementation. My forecast is that the mandate will be overturned 5-4.

• Three, it’s beginning to look like Romney. I think he stands a 50:50 chance of beating Obama. If he does, each state may have its own approach to care , can handle its Medicaid population as it sees fit, and can have its individual mandate if it wants.

• Four, hospitals, doctors, and health plan will continue to rapidly consolidate, with some owning each other, with dominance of local and regional markets, with negotiating power, with higher prices, and with anti-trust issues.

• Five, as new revenue models offering “free” EHRs, computing off-site in “the Cloud,” and hand-holding facilitating “meaningful use” bonuses, EHR use will take off like wild-fire.

• Six, more and more physicians will exit from practices depending on 3rd party revenues and will go to concierge, retainer, and direct-cash practices.

• Seven, hospitals, physicians, and insurers will enter retail markets to snare business from individual consumers, who will become an increasingly larger part of insurance market.

• Eight, primary care shortages will grow, concern about their future will escalate, and more nurses and physician assistants will be trained and recruited to fill the gap.

• Nine, accountable care organizations will be very much in the news as the ten “pioneer” ACOs hit the streets on January 1, 2012, and other providers wait and see if outcomes improve and savings eventuate.

• Ten, venture capitalists, sensing openings in the vast health care industry, will be actively searching to find entrepreneurs, including physicians, who have marketable ideas on how to make care cheaper, better, more convenient, and more “disruptive,” i.e., useable for less sophisticated folk below the specialist level.

Tweet:Herein are 10 forecasts for health care as envisioned by a physician.

Wednesday, December 28, 2011

The widespread failure of all-metal hips may cost taxpayers, insurers, and employers billions of dollars in coming years.

New York Times, “Hip Implants’ Common Failures Brings High Costs ,” by Barry Meier, December 28, 2011

December 28, 2011 - Today’s New York Times’ front page, left column , article on the failure of all-medal hips replacements is a cautionary-tale on the limits of technology.

Beware, the tale warns, what patients wish for and what medical device manufacturers and doctors deliver.

One-third of 250,000 hips replaced last year, and 500,000 of all hips implanted to date, are of the all-metal type. News of widespread failures of all-metal hip failures have set off a flurry of medical of more than 5000 lawsuits and complaints so far. with more surely to come.

The problem with these all-metal hips seems to be that the all-metal surfaces grind against one another, causing a shrapnel release of tiny metal parts which damage adjoin tissues and the joint itself.

With orthopedic surgeons,

It’s no longer pedal
to the metal.

It’s backing off from the all-metal hip joint,
No more can they to its use point or anoint.

All-metal hips have become an Achilles heel,
A non-fatal condition that does not heal.

Its past use puts them in a fettle,
With potential lawsuits to settle.

The trained nurse has become one of the great blessings of humanity, taking a place beside the physician and the priest, and not inferior to either in her mission.

Sir William Osler, MD, (1849-1919), Aequanimatas

December 28, 2011 – The following blog appeared a few days ago in The Health Care Blog.

The author, Merrill Matthews, resident scholar at the Institute for Policy Innovation in Dallas, Texas, beautifully sums up the plight of primary care physicians and the bright road ahead for nurses. This post originally appeared at Forbes.

The systematic downing of physician incomes under Obamacare, projected to reduce Medicare doctor pay to less than that of Medicaid by 2019, may come back to haunt Democrats politically as tens of thousands of doctors exit from clinical medicine and as tens of millions more Medicare and Medicaid recipients enter government entitlement rolls.

Matthews Blog

"There are lots of losers in President Obama’s effort to remake the U.S. health care system, and chief among them are the doctors. But there are also winners, especially nurses and physician assistants (PAs). Indeed, nurses and PAs win big in part because doctors lose badly."

"Surveys repeatedly show doctors are fed up with low reimbursement rates from Medicare and even lower from Medicaid, which have increasingly led doctors to no longer see new patients in those government-run plans. For example, a recent Texas Medical Association survey found that “34 percent of Texas doctors either limit the number of Medicare patients they accept or don’t accept any new Medicare patients.” Even more do not accept patients with Medicaid."

"Then there’s the heavy-handed regulations and requirements from both government and private health insurers. Complying with all those requirements and paperwork creates expensive and time-consuming administrative burdens. And to top it off, there’s the looming shadow of a high-cost lawsuit if things don’t turn out well."

"And that’s all before ObamaCare kicks in, which will exacerbate every one of those problems. So it’s little wonder that there are physician shortages, especially in lower-paying primary care, and those shortages are only going to get worse if ObamaCare succeeds in getting an estimated 32 million more Americans insured."

"The increased demand for medical care and lower reimbursements—which is one of the primary ways ObamaCare will try to hold down costs—is a recipe for a mass exodus of doctors willing to practice medicine. As Physicians Practice reported in August from its physician survey: 'Nineteen percent say they plan to move to another position in the same field. An equal amount says they plan to leave medicine—not to retire, but to pursue something new.' "

"So who will provide the needed care if the doctors exit? Enter the nurses and physician assistants."

"If ObamaCare withstands the Supreme Court challenge and Republicans fail to “repeal and replace” it, more nurses will be called on to provide more care that historically has been provided only by physicians—a trend that is already happening."

"As the PBS NewsHour reported last May: 'The scope of what nurses can do medically has also been growing for the past decade, at a time when the pool of primary care, or family doctors, has been shrinking. … And more and more are working on their own, especially in poor inner-city neighborhoods and rural areas, where there are few doctors in private practice.' "

"The U.S. Bureau of Labor Statistics (BLS) predicts that the registered nurse (RN) will be the fastest growing profession between 2008 and 2018. And the profession is financially rewarding. The BLS estimates that the average salary for a registered nurse in 2010 was $67,720, or $32.56 an hour. In 2009 the average salary was $63,750, or $30.65 per hour. That’s about a 6 percent increase in a bad economy when millions of Americans were just thankful to have a job."

"However, as in all professions, some segments do better than others. A recent survey of 3,000 nurse practitioners conducted by “Advance for NPs and PAs” found full-timers earned $90,770 in 2010. But nurse practitioners in emergency departments earned on average $104,549. Good salaries considering that Medscape reports that nearly half of family physicians, with all their additional training and educational expenses, made between $100,000 and $175,000 in 2010."

"Because ObamaCare will never bend the health care cost curve down—as the president repeatedly promised it would—something will have to give. And doctors’ reimbursements will be on the amputation table."

"Those payment cuts will surely be politically messy. Just look at the current fight over Medicare reimbursements. Yes, Congress is trying to stop the scheduled 27 percent cut in physician reimbursements—part of a 1997 law that says if Medicare grows faster than a certain rate, physician reimbursements must be cut to balance it out. Because Congress postpones the cut every year, the scheduled cut keeps getting bigger."

"That means doctors have received no significant Medicare increase in more than a decade, even though their costs to provide care go up every year. In effect, the Medicare reimbursement problem has resulted in a 20 percent cut in inflation-adjusted dollars. But what is an unacceptable cut for physicians could be an attractive increase for lower-earning nurses and PAs, many of whom are willing to take the lead on providing more comprehensive care."

"While it may make sense to expand nurse and PA responsibilities, that decision should be made from the bottom up, in the context of doctors and nurses looking for ways to provide quality patient care at a reasonable cost. It should not be the result of top-down micromanagement and price controls that leave health care providers scrambling to find a way to exist under Washington-imposed regulations. Yet that’s exactly what ObamaCare will do."

Tweet:Future prospects for physicians are bleak, while fortunes of nurses and physician assistants are bright.

Tuesday, December 27, 2011

December 27, 2011- Luis Pareras, MD, PhD, MBA, of Barcelona, Spain, and I are contemplating writing a book on physicians seeking venture capital to escape the fetters of practice and to launch innovative ideas.

Dr. Pereras is a venture capitalist. He lives in Europe. In Europe, aging populations, plummeting birth rates, and soaring costs makes it hard to sustain overly generous social welfare states. I live in the U.S, where, to a lesser degree, a similar situation is emerging.

Here Medicare is approaching bankruptcy. Medicare is the single biggest contributor to our growing budget deficit. In Europe, centralized bureaucracies often smother innovation. This may soon be the case in the U.S. Europe and the U.S. are inextricably interlocked sectors of the global economy - economically. clinically, but not always culturally.

Nevertheless, both physicians in Europe and the U.S. are unhappy because government is cutting their pay and ramping up regulations to make national ends meet. Some physicians in Europe and the U.S are turning to venture capitalists to get the money required to launch start-up health –related enterprises. Others rely on their own finances or angel investors.

Of Wikipedia’s list of 91 notable venture capital firms, only 8 (8.8%) are headquartered in Europe, 4 in London, 2 in Germany, 1 in Paris, and 1 in Moscow, while 78 (85.7%) are in the U.S., and 4 elsewhere (2 in Singapore and 2 in Israel).

In the U.S, 41 are in California, 13 in Massachusetts, 7 in New York, 5 in Texas, 3 in Pennsylvania, 2 in Connecticut, 2 in District of Columbia, 2 in Virginia, with single firms in Kansas, Washington State, Colorado, Maryland, and Rhode Island.

Why such a book? The reasons are complicated and overlapping. Physicians are by nature entrepreneurial. They often rely on other people’s money. Many physicians want to escape from negative practice environments – mounting bureaucratic burdens, declining reimbursements, increasing expenses, decreasing autonomy and practice satisfactions.

Some physicians are willing to take entrepreneurial risks, to roll the dice with their reputations and their own money, or money from relatives or angel investors. Some are seeking refuge from overheads imposed by 3rd parties, public and private, Still others are entering concierge practices or practices requiring only direct-cash transactions. Many believe that once they are freed from 3rd parties, they can provide cheaper and better care through “disruptive innovations.”

But how? How does one change one’s practice? How does one access venture capital, the financial oxygen required by startup enterprises? Where are the best sources of reliable venture capital? What are the economic and control tradeoffs between individual entrepreneurs and investors? What is the process by which one embarks on an alternative career? In Dr. Peraras’ excellent book, Innovation and Entrepreneurship in the Health Care Sector: From Idea to Funding to Launch ( Greenbranch Publishing, 2011, 460 pages), he has described the process in detail.

Dr. Peraras and I envision a smaller book – full of concrete case studies illustrating why entrepreneurial physicians have either succeeded or failed in new ventures. We want to tell where physician entrepreneurs got their money. We want to describe the pratfalls, beartraps, and opportunities lurking out there . We want to interview these entrepreneurs. We want to ask them the lessons they learned. We will list notable venture capital firms. We will take note of health care trends barreling down the health care pike.

An instructive example of what is going on the venture capital field appeared recently in an interview with Rebecca Lynn in the December 11 edition of HealthLeaders Magazine. Ms. Lynn, a partner in Morgenthal Ventures, a venture capital and private equity firm in Menlo Park, California, had this to say.

“Some argue the healthcare industry is innovation-proof. It is risk adverse. It is too slow – even unwilling to change. It is too complicated and regulated to change.”

She disagrees.

“Change will come from outside entrepreneurs unfettered by the status quo – who can tame the healthcare data beast and who are willing to try new ideas – such as outsourcing some care to patients themselves.”

“The only way to get the data is through an EMR…that’s automatically populated by your physician, by the labs, and by the pharma companies. The data’s got to be in the cloud, and it has to be free.

'One thing we’ve learned is that doctors pay for nothing. It’s not a slam against doctors. It’s just a fact of life.”

“That’s why our firm invested in PracticeFusion – a free web-based EMR with an open application program interface that grants access to other applications.”

“Start-ups must get creative when it comes to revenue models. Offer a product that’s free, and it will take off like wild fire.”

“Patients have proven they are capable of tending to their own health care issues . Diabetics manage to measure their insulin levels, and women take pregnancy tests at home all the time…The trends to passing to patients some of the responsibility of their own care will continue – from ordinary lab tests to in-home medical devices and technologies such as blood pressure cuffs, glucose meters, and smart scales.”

“We cannot afford the healthcare industry as it stands. You hve to look at ways to deliver better care, increase efficiency, reduce readmissions, and reduce costs. That’s why healthcare has to be readmitted.”

Tweet: A health care innovation revolution is at hand. Physician entrepreneurs with venture capital access will lead that revolution,

Friday, December 23, 2011

This Christmas I will be thinking of my two sons who can’t be with us. One will be selling goods for Brooks Brothers in New York City during their peak season. The other is an Episcopal Priest in Madrid, Spain, where he serves as an assistant to the Anglican Bishop of Spain.

I asked my priest son, who is in Spain on a one year Amy Lowell Fellowship, awarded to an American poet each year, to name his favorite Christmas poem. He nominated James Merrill’s “The Christmas Tree.”

James Merrill (1926-1995) wrote this poem just before his death, with full knowledge he was dying. The poem celebrates life and Christmas.

My son tells me in Spain people dig up their Christmas trees, preserve them in pots, then replant them when the two week Christmas celebration ends on January 6. That seems fitting. It gives the Spanish nearly a year to regrow, renew faith, and spirituality. Perhaps we Americans should have an annual ritual of uprooting, repotting, and replanting.

I am grateful to you, my blog readers, as I try to explain the transformation and reformation of medicine and health care, which I pray will better our physical, spiritual, and economic health.
Christmas Tree by James Merrill

To be
Brought down at last
From the cold sighing mountain
Where I and the others
Had been fed, looked after, kept still,
Meant, I knew--of course I knew--
That it would be only a matter of weeks,
That there was nothing more to do.
Warmly they took me in, made much of me,
The point from the start was to keep my spirits up.
I could assent to that. For honestly,
It did help to be wound in jewels, to send
Their colors flashing forth from vents in the deep
Fragrant sable that cloaked me head to foot.
Over me then they wove a spell of shining--
Purple and silver chains, eavesdripping tinsel,
Amulets, milagros: software of silver,
A heart, a little girl, a Model T,
Two staring eyes. The angels, trumpets, BUD and BEA
(The children's names) in clownlike capitals,
Somewhere a music box whose tiny song
Played and replayed I ended before long
By loving. And in shadow behind me, a primitive IV
To keep the show going. Yes, yes, what lay ahead
Was clear: the stripping, the cold street, my chemicals
Plowed back into Earth for lives to come--
No doubt a blessing, a harvest, but one that doesn't bear,
Now or ever, dwelling upon. To have grown so thin.
Needles and bone. The little boy's hands meeting
About my spine. The mother's voice: Holding up wonderfully!
No dread. No bitterness. The end beginning. Today's
Dusk room aglow
For the last time
With candlelight.
Faces love lit,
Gifts underfoot.
Still to be so poised, so
Receptive. Still to recall, to praise.

Tweet: I shall pause writing this blog until after Christmas to celebrate the season and to reconsider the meaning of life and health

December 22, 2011- Ekekiel Emanuel, MD, PhD, (born 1957), former associate professor at Harvard Medical School, bioethicist at NIH, and Obama health advisor, and, as of September 2011, a Professor at University of Pennsylvania Medical School and Wharton and regular New York Times contributor, expresses these opinions in a December 19 in a NYT’s Opinionator column entitled “For Medicare, We Must Cut Costs Not Shift Them.”

“The Affordable Care Act already created a mechanism to reduce spending in Medicare to the growth in gross domestic product plus one percentage point. Starting in 2020 the Independent Payment Advisory Board is required to submit proposals to cut Medicare spending if the growth in spending exceeds that level. However, the board is specifically prohibited from rationing care, raising taxes or premiums, increasing cost-sharing, restricting benefits or modifying eligibility — thereby protecting beneficiaries. Its proposals become law unless Congress or the president votes to institute other reforms that save as much money.”

"What should be done about Medicare? To address the root of the cost problem, we must change how we pay doctors and hospitals. We must move away from fee-for-service payments to bundled payments that include all the costs of caring for a patient, thereby encouraging providers to keep patients healthy and avoid unnecessary services. Medicare should announce that it will make this change by Jan. 1, 2022, and that it will begin by switching to bundled payments for cardiac and orthopedic surgery within one year and for cancer patients within five."

"Premium support will not reduce the government’s costs without shifting those costs to older people who can’t afford them. Only a plan that transforms how we pay doctors and other health care providers can do that.”

Wednesday, December 21, 2011

The independent, private practice model will be largely, though not uniformly, replaced. Most physicians will be compelled to consolidate with other practitioners, become hospital employees, or align with large hospitals and health systems for capital, administrative and technical resources.

The Physicians Foundation, “Health Reform and the Decline of Physician Private Practice, “ A White Paper Examining the Effects of the Patient Protection and Affordable Care Act on Private Practices in the United States, October 2110

December 21, 2011- This week Health and Human Services announced with considerable fanfare 32 "Pioneer" Physician Organizations that qualified after competition to become “Pioneer” Accountable Care Organizations (ACOs). These ACOs will begin their work on January 1, 2012 and are designed to save Medicare $1 billion over the next 5 years by boosting quality while improving outcomes and reducing costs.

These 32 organizations, selected from among 80 applicants, hail from 18 states. They now care for 880,000 Medicare beneficiaries. Six of the fledgling ACOs are from California, 5 from greater Boston, 4 from Minnesota, and 3 from Michigan.
The 32 "Pioneers"

These organizations hardly represent U.S. physicians as a whole. Many are in the most progressive cities in the more liberal states of the U.S. – in California, Massachusetts, Minnesota, Michigan, and New England.

Great swaths of the U.S., 32 states in all, have no ACO representatives.

These states include those in the far West (Hawaii, Alaska, Oregon, Washington State, Idaho, Montana, Utah, Wyoming), the Midwest and Southwest (North and South Dakota, Nebraska, Oklahoma, Missouri, Ohio, Kansas), the entire South (North and South Carolina, Georgia, Alabama, Mississippi, Tennessee, Kentucky, Arkansas Louisiana, Virginia, West Virginia), parts of the East (Connecticut , Delaware, Maryland, New Jersey).

These organizations do not include physicians and health systems that care for 47 million other Medicare recipients. Moreover, many of the “pioneers” are hardly that. They are well-established groups with salaried physicians and the infrastructure, finances, and administrative teams to handle the bureaucratic demands of ACOs.

It may be, of course, that 88% to 90% of physicians who practice outside of these “pioneer” ACOs, will see the light and invest money, time, and energy and will take the risk of creating these new organizations. It may also be that prestigious organizations like Mayo, the Cleveland Clinic, the Marshfield Clinic, Geisinger, academic medical centers, like Duke, Johns Hopkins, and prestigious New York and Pennsylvania centers, and other intergrated medical school-centered systems, will join the reformation and climb upon the ACO bandwagon.

It will be a waiting game to see if the 32 “pioneers” can produce results envisaged by Washington CMS and HHS planners and founders of these early ACOs.

Maybe, just maybe, other physician organizations will cross the Great Divide between private practice in fragmented solo or small groups to an organizational Nirvana. It will take more time, more experiments, more results, and more federal incentives.

When one uses the term “Accountable Care Organization,” a fundamental question arises. ”Accountable to whom?” To the federal government? To the experts and managers who designed these organizations? To the organizations who implement them? To the defined populations of the elderly they serve?
Tweet:Health and Human Services has announced 32 “pioneer “ medical organizations have agreed to become experimental ACOs, starting in January 2012.

Tuesday, December 20, 2011

It’s unwise to bet against the House, the President, and the Law, but you might get lucky.
Anonymous

December 20, 2011 - In 2009, I wrote a book entitled Obama, Doctors, and Health Reform: A Doctor Assesses the Odds for Success (IUniverse).

The book comes to mind as I assess the current odds on the Presidential race and health reform repeal as set forth by these two sources.

One, Intrade.com, which portrays itself as the world’s leading prediction market, with political odds as seen by the wisdom of crowds, viz, people betting on outcomes.

 Mitt Romney to be Republican presidential candidate, 67.1% chance

 Newt Gingrich to be Republican presidential candidate, 9.9% chance

 Jon Huntsman to be Republican presidential candidate, 5.3% chance

 Ron Paul to be Republican presidential candidate, 8.3% chance

 Rick Perry to Republican presidential candidate, 2.6%

 Barack Obama to be re-elected as president, 50.6% chance

Two, Real Clear Politics, favorability odds.

 Obama job approval, approve 45.8%, disapprove 50.0%

 Congressional approval, approve 11.3%, disapprove 83.7%

 Country going in right direction, 23.0%, wrong direction 71.2%

 Obama and Democrats health plan, approve 36.4%, disapprove 49.8%

 Favor repeal of health plan 49.7%, against repeal, 39.3%

Conclusion

Odds favor Mitt Romney as Republican candidate for President, and President Obama as eventual winner. Odds indicate Most Americans disapprove of health reform law and desire its repeal.
Tweet:Odds indicate Presidential election in November may depend on Supreme Court decision in June on constitutionality of health reform law.

In my opinion, Stillwell's reports accurately mirror attitudes, fears, and perceptions of the ACA (Accountable Care Act. aka, Obamacare). It has now been 21 months since the Act's March 23, 2010 passage. The nation's citizens, including its physicians, remain divided on the wisdom and consequnces of its passage.
_____________________________________

We are about to end the year, much like it started. There has been a great deal of noise and few results toward the goal of creating a new healthcare system that has increased quality and value for the consumers and drastically reduced costs to government.

Repeal or retention of Obamacare and overhaul of Medicare/Medicaid as part of the need to control healthcare spending will remain a top priority of both Democrats and Republicans as we leave 2011 and head into 2012.

Even though the need to control healthcare spending grows by the minute, Congress will adjourn without addressing the problem.

An annual report from the Medicare Office of the Actuary estimates health care spending by 2020 will double and federal, state and local governments will pay half –50 percent—of the cost. The report indicates health care spending will average 20 percent--of the nation’s GDP in 2020, up from 17.6 percent in 2010.

Looking at those numbers in another way, health care spending will almost double to $4.6 trillion from $2.6 trillion in 2010. And, health care spending in 2020 will cost $13,710 for each man, woman, and child in America, up from a 2010 per capita cost of $8,327.

Surprisingly, the analysis concludes that President Obama’s health care law only plays a modest role in growing costs, even though it provides 30 million uninsured Americans with insurance coverage. Blamed are the increasing numbers of aging Americans and the high cost of medical innovations.

Obviously, such statistics and the mounting political rhetoric about the urgent need for drastic action have made the public very nervous. They rightly fear that medical care will cost more and their access and choices for treatment will be less. Consequently, health care and the economy will be defining issues in the upcoming Presidential primaries and next year’s November election.

Matter of fact, disenchantment with Obamacare—the Affordable Care Act (ACA) passed March 23, 2010-- continues to grow. A recent Associated Press poll shows support for his law has dropped to 29 percent with 49 percent opposing it. Also, only 15 percent believed that government should be able to force citizens to purchase health insurance while 84 percent say “not.” The U.S. Supreme Court will determine the fate of this individual mandate, which is part of the Obama bill, this coming year.

These polling numbers make the Republican political strategy for 2012 obvious. They plan to be very visible in their efforts to appeal the law. Remember, the GOP-controlled House’s first legislative effort this year was to pass a repeal of Obamacare, which went nowhere in the Democratic-controlled Senate.

Expect more of the same in 2012. Insiders say the GOP focus will be on repeal of two provisions in the Obama law—the Independent Payment Advisory Board (IPAB) and the CLASS Act.

The Obama Administration had put the CLASS Act, the health care law’s long-term care provision, on hold because staff at the Department of Health & Human Services (HHS) couldn’t find a way to make the program solvent. Therefore, the GOP contends it should be repealed and is moving legislatively forward to do so.

Republicans warn that the IPAB, a 15-member board, has too much power. The law authorizes it to make reductions in provider payments if they increase too fast. Congress could overrule the panel, but only with a super majority in the Senate, or by devising an alternate plan that saves the same amount.

A political solution for both of these provisions is possible, but there appears no likely outcome in 2011 for the greatest of the challenges facing the nation’s health care system: Medicare reform.

Political observers believe Medicare reform only comes from a bipartisan plan. Subsequently, there is a great stir in the capital over a development this past week that saw a bipartisan legislative proposal to revamp Medicare come from two unlikely individuals--Rep. Paul Ryan(R-Wis.) and Sen. Ron Wyden (D-Ore.).

Ryan, chairman of the House Budget Committee, was the chief sponsor last April of a budget resolution which passed the Republican-controlled House with a provision limiting the federal government’s Medicare spending while requiring seniors to pay for coverage and eliminated the traditional fee-for-service option.

The Senate ignored Ryan’s proposal, which upset many of the nation’s seniors. And, it should be noted, 34 percent of the seniors 60 or older regularly vote. And there now are 47 million Americans on Medicare.

The new Ryan-Widen plan expands choice by permitting private health plans to compete with the government for seniors. The new system, which would start in 2022, also would include a premium support system intended to lower the costs of private plans by comparing them to Medicare. Providers and drug companies would face reduced support if spending rose more than one percent GDP.

Reaction was predictable. House Speaker John Boehner(R-Ohio) called it a bipartisan idea worthy of consideration. House Minority Leader Nancy Pelosi (D-Calif.) charged that the plan shows the GOP want Medicare to “whither on the vine.” White House Press Secretary Jay Carney called the plan radical and GOP Presidential candidates Mitt Romney and Newt Gingrich praised the plan.

None of the comments appeared to deter Widen and Ryan from promoting their plan, which still lacks cost projections and other key details. The men don’t intend to introduce the legislation until after the November 2012 election, only putting the proposal out there now as a marker for discussion.

Their timetable makes sense. A divided Congress, and reelection-anxious President, seems destined to avoid a real solution in 2012-- until after November’s results. By then, spiraling deficits, threatening the nation’s economic wellbeing, will force all the politicians to address the matter. For better or worse, we finally can look into a crystal ball— in 2013 for sure--and see our health care system dramatically transformed and reshaped to meet budgetary challenges.
Tweet:Retention or rejection of the health reform law preoccupies physicians. The law's fate remains uncertain.

To scam Medicare is not to give a damn for taxpayers. Money is money whether you earn it or steal it.

Anonymous

December 19, 2011- Christine Seivers of medicalbillingandcoding.org sent me the following list of common Medicare scams. I have edited and shortened her copy to fit my blog. Her blog was sent out on December 18.
______________________________________

1. The Poser Scam

One common way to scam Medicare is to pose as a Medicare employee, a practitioner, or insurance representative. These fraudsters call, email, or send letters asking for personal information that includes bank, Social Security, and Medicare numbers.

2. The Healthcare Reform Scam

Healthcare reform is on the lips of everyone these days, and scammers are using it to cash in. Many adults don’t know what the new health care legislation actually entails. That’s just the way criminals want it. It makes many Americans easy targets for scams, like those that claim to sell "healthcare reform insurance" that purportedly protects seniors from any losses to their Medicare or any fines they make incur from not meeting guidelines.

3. The Free Lunch Scam

There is no such thing as a free lunch. Scammers in low income areas are taking advantage of the neediest Medicare recipients by drawing them in to fake health care clinics with promises of free food or gifts. Once they have the victim where they want them, they get Medicare numbers through coercion and then use them to commit Medicare fraud.

4. The Kickback Scam

Scammers might offer you a cut of the take in exchange for your Medicare number, but they won’t put it like that. If anyone ever promises you any gift or monetary rewards for your Medicare number, decline their offer immediately. You’ll be drawn into the scam, and could face criminal charges for your role.

5. The Refund Ripoff Scam

As part of the Affordable Care Act, many senior Medicare recipients may be eligible to receive a refund from the government of $250 to help cover their prescription drug costs. Criminals have pounced on these checks as an opportunity to make some extra cash and scam some Medicare numbers at the same time. Many call seniors and tell them that they need to confirm Medicare numbers to send out the checks. Medicare numbers are like credit card numbers: they should never be given out to strangers over the phone.

6. The Imposter Employee Scam

.Anyone can claim to work for the government. Some criminals looking to scam those on Medicare will call or even come to the home of recipients asking for personal information like Medicare numbers and bank accounts. Never trust someone who calls or visits you out of the blue looking for information of this kind.

7. The Free Medical Supplies Scam

Exchanging medical supplies, which are usually of very low value, for Medicare numbers is not a bargain, it’s a scam. If someone tells you that an item is free but they just need your Medicare number for their records, you’re better off buying the items on your own.

8. The Not Usually Covered Scam

If something isn’t covered by Medicare, it isn’t covered. Period. If your provider or someone you don’t know tells you that an item isn’t covered but they know how to bill it so you won’t have to pay, that might sound great. But it’s also fraud and can get you, and that provider, in a lot of trouble.

9. The Extra Equipment Scam

Those with diabetes, arthritis, and sleep problems are frequent victims of this scam. Salespeople will go to homes of those they know suffer from these conditions and try to get them to buy extra equipment, often things that they really don’t need. It sounds great because these extra items can be billed to Medicare and you won’t have to pay a thing.

10. The New Card Scam

Another way scammers are taking advantage of new health care regulations is by telling seniors that in order to keep receiving benefits or get their refund checks they’ll need to get a new Medicare card. This simply isn’t true.

11. The Medical Decisions Scam

Some unscrupulous insurance agents have been taking advantage of Medicare policy holders. Some are sending out release forms that allow agents to make decisions on their behalf. Never, ever sign anything without reading through it first and making sure you understand it. If it’s confusing, get a friend, family member, or lawyer to look over it before signing.

12. The Fancy Tests Scam

Some doctors and nurses are at the center of Medicare frauds. They make their money from scamming Medicare by scaring or coercing patients into getting unnecessary and expensive tests. Your medical provider should never use pressure or scare tactics to get you to consent to any medical decision, it’s just unethical. If you feel this is going on, get a second opinion.

A Verse for Medicare Scammers

You don’t have to go on the lam,
When Medicare is so easy to scam.
You nee a Medicare and street number,
And you can be cool as a cucumber,
For the Feds are in deep slumber.

Tweet:Scammers defraud Medicare of $60 billion a year through these 12 schemes.

Sunday, December 18, 2011

December 18, 2011 - I enjoy reading New York Times’ editorials. The editorials tell you how things could, should, and ought be in opinions that are fit to print and in a world that’s fit to live in.

The editorials are predictable. They adore the Democratic party, abhor the Republican Party, and deplore anything that distracts from Big Government’s mission.

Take today’s editorial, “Working with Medicare: Reforms Could Save Hundreds of Billions of Dollars – without Scrapping the System.”

Here the operative word is "could", but the implied "should" and "ought to" are not far behind.

The editorial says:

1. It is “skeptical” that the latest Medicare proposal advanced by Paul Ryan (R- Wisconsin) and Ron Wyden (D-Oregon) suggesting a blend of today’s Medicare system blended with a private option of premium support would work(Anything that changes present Medicare, scheduled to go broke in 2016, is verboten).

2. Medicare insurance is superior to private insurance (even in face of the fact that Medicare is decimated by $60 billion of fraud and abuse while this is rare with private insurance).

4. Medicare pays too much, much more than needed for a “reasonable profit" to provide good care” to providers and “could save" $40 billion by paying skilled nursing facilities and nursing homes less and $200 billion more by aggressively managing coordinating all care ( presumably a D.C. bureaucrat should decide what constitutes a "reasonable profit").

5. Raising the Medicare entry age from 65 to 67 “could save" $125 billion, but it’s a bad idea “only if the health reform law remains in place” (In other words, Medicare is sancrosanct and cannot be changed in any way).

6. Real costs savings “could" occur if incentives are removed from doctors to perform more tests and procedures (no mention is made of patient and malpractice pressures to do these tests and perform these procedures).

7. Medicare “could save" $30 billion with a $550 annual deductible , a 20% copay for all service, and a cap on out-of-pocket spending, but it’s a bad idea unless it would protect the poor( part of the "poor"are families of four making up to $108,000).

8. Medicare means testing for those making over $85,000 a year "could save" $50 billion in ten years and $200 billion if it rasised premiums for everybody, but “that seems risky” ( What"risky" means is not explained).

9. The real solution is the reform law “that makes a start by reducing doctor pay and pay for Medicare Advantage Plans , that “could save" $400 billion and even more if followed by pilot projects promising to reduce Medicare costs even more ( If only those greedy doctors and Medicare consumers desiring options would play ball, all would be well).

10. No matter what, “Medicare still works better than most private plans and offers the best hope for promoting wider reforms"(translated: the New York Times believes the health reform law and Medicare should be left alone, even if headed towards bankruptcy. In time, 10 years, it believes the new law will cut costs , preserve, and improve the health system).

Tweet:The New York Times, in a predictable editorial, says Medicare could, should,and ught to save Medicare by saving billions of dollars.

Saturday, December 17, 2011

It is not enough to have a good mind. The main thing is to use it well.

Descarte (1596-1650)

One man who has a mind and knows it can always beat men who haven’t and don’t.

George Bernard Shaw (1856-1950)

December 17, 2011 - When I think of Newt Gingrich, I think of a mind at work and at play. He has a good mind, even a grandiose mind, and he is always playing around with new ideas. He has a mind rich in experience,brimming with political anecdotes and historical lore.

But, say critics, it is a fickle and opportunistic mind. Six years ago, he was for the individual mandate, now he is against it. Now he is backing off his support of electronic records.

Some say these changes of position represent grandiosity, even pomposity, but Gingrich supports say these shifts speaks more of virtuosity. Gingrich can, admirers say, out-think and out-talk other politicians in tense situations, like debates.

On some issues – like electronic medical records and a comparative effrectiveness research – Gingrich claims he is steadfast. Data, he opines, enriches the mind, expands mental horizons, and corrects biases.

Of Obama's stimulus package of $787 billion in 2009, with $27 billion targeted for EHRs, Gingrich told the New York Times that same year, “The president should be applauded for making this a vital priority and a key part of his economic stimulus package.” Today Gingrich is against Obamacare.

In Human Events, he wrote, “In our country the road to humanity begins with something called comparative effectiveness research.”

Of his backing of EHRs and comparative effectiveness research,Gingrich asserted, “Initially, they’ll be rejected. Let’s be clear: This is not a city that likes innovation. It’s not a city that likes to think deeply. It’s a city that memorizes a handful of phrases and uses them in nine sound bites.”

Now there’s a man who knows how to pose as a Washington outsider, while making his fortune through insider contacts. Gingrich collected consulting fees at the Center for Health Transformation, which he founded, by serving as spokesperson for clients like Siemens, GE Healthcare, Allscripts, MedAffinity, and Microsoft and other firms selling, developing, or pushing EHRs.

Gingrich a man who knows his own mind. He reserves the right to change his mind, depending on new knowledge. Flip-flopping, changing one'v view in the fact of new information, can also be interpreted as the mark of a mature mind.

Tweet:As a presidential candidate, Newt Gingrich has an on and off record of support for EHRs.

The National Highway Safety Board announced plans to ban smartphones for drivers, medical authorities said computer use among doctors and nurses potentially harms patients, and Herman Cain withdrew from the Republican race because of distractions caused by irresponsible bloggers.

In cars nevermore use of smart phones,
It turns drivers into distracted drones.

In operating suites, nevermore IT devices,
It causes surgeons to make wrong slices.

Thursday, December 15, 2011

It may seem a strange principle to enunciate as the very first principle in a Hospital that it should do the sick no harm.

Florence Nightingale (1820-1910), Notes on Hospitals (1859)

Hospitals in their present form will not disappear, but their role will change dramatically.

Anonymous

December 15, 2011 - A world without hospitals as they now exist is an improbable thought. Yet it is well underway.

The health system is shifting from expensive hospital specialist-dominated care to more affordable primary care and to home-based self-care. General hospitals will, of course, continue to exist as bedrock large employers in most communities and as providers of the last resort, but they are shedding their brick and mortar mentalities and facilities.

Powerful Centrifugal Forces

Powerful centrifugal forces are pulling patients out of hospitals and ERs. These forces are economic,sociological,and technological. They are turning hospitals inside out. They are shrinking centralized facilities and enlarging outpatient outreach activities.

The forces are focusing on cardiovascular and oncological diseases. They are being unfurled under the health reform banner, but there is more to it than that. It is survival of the fittest and the biggest. Government at all levels is driving change. Hospitals are moving aggressively into outpatient and retail arenas. Large and small employers are seeking refuge from high costs; physicians are searching for autonomy; and consumers are questing after lower costs, more convenience, more empowerment, more personal care.

Fear of hospital-acquired infections and other hospital safety hazards are factors as well. All parties are focusing on simpler solutions to reduce complexities of care. People want more care outside of institutions. They prefer to walk-in rather than be carried-in for care.

Christensen's Disruptive Innovations

Here's how Clayton Christensen, a Harvard Business School professor who wrote The Innovator’s Dilemma in 1997 and who coined the term “disruptive innovation,” describes events. Christensen considers himself an innovator. He co-founded Innosight, the Innosight Institute, Innosight Ventures, and Rose Park Advisors and Venture Capital Group.

Christensen views the fundamentals and sequence of transformational events this way.

• Its essential change elements are: 1) investments in diagnostic technologies that simplify care outside hospitals, e.g. ultrasound in hands of doctors in their offices; 2) business model innovations, such as retail and walk-in clinics; 3) creation of more integrated fixed-fee health systems along the lines of Intermountain Healthcare, Kaiser, and Geisinger, while phasing out of variable and traditional fee-for-service care.

• A transition to simpler care aided by technologies and provided by less sophisticated personnel outside of hospitals – in doctors’ offices, outpatient settings, retail clinics, and in patients homes using telemedicine monitoring and communication.

• HSAs with high deductible plans would gain ground, capturing as much as 50% of health plan market by 2014.

• Patients would take more responsibility for their own care – self-care would go mainstream.

According to John Peabody, MD, PhD, and Vice-President, of Sq2, a future- focused health care consulting firm, much of what Christensen is predicting and advocating for hospitals, is already taking place.

Peabod's Forecastes for Hospitals

From 2011 to 2021, Peabody projects for hospitals:

• Inpatient loads to drop 3% while outpatient work will increase 32%.

• Cardiovascular and cancer inpatient care, hospitals’ two profitable service lines, to decrease by 27% while outpatient care will go up by 19%.

• Outpatient work for pneumonia, the scourge of the elderly, to spike by 23% while inpatient care for pneumonia to plunge by 48%.

• Will the future of hospital-doctor relationships be one of cooperation, collaboration, or cooptation? (On the last bullet point, "cooptation" means hospitals take over the practice of medicine).

• What is the role of hospitals in health reform – hospitals after all have already agreed to $155 billion in Medicare cuts under Obamacare?

But I digress. What is the hospitals’ problem with the Republican legislation? What is the big deal? The Senate will probably not even take up the bill up anyway.

Simply this: Hospitals would have to pay $17 billion of the $38 billion required for the “doctor fix, ” a 2 year reprieve from the 27% Medicare doctor pay cuts.

How? Starting in 2013, the bill would lower hospital Medicare payments government now pays for uncollected bills, copays, and deductibles and for the administrative costs devoted to collecting these unpaid items.

Hospitals say this additonal cost burden would be devastating. Uncollectibles are soaring because of the recession, diminished state Medicaid funding, and a 2% cut due the “sequester” in the wake of the failed budget bill.

The hospitals’ hostile reaction to the Republican legislation raises these questions.

. What is the basic attitude of hospitals toward independent doctors, who may practice largely outside the hospital environment but who may depend on hospitals for their work and livelihood?

• If the 27% cut goes through, can hospitals live without doctors who will no longer accept Medicare or Medicaid patients?

Answers to these questions may be moot, i,e.not relevant in the present practice environment.

• Many of the doctors who cease or cut back on practices will be older independent doctors who practice outside of hospitals.

• Many will go into cash-only practices, concierge practices, walk-in clinics, and urgent care centers outside of the province of hospitals.

. Many primary care doctors will work for government-sponsored Community Clinics, which already care for 20 million Americans.

• Some of the practice vacuum will be filled with physician extenders – nurses, nurse practitioners, and physician assistants.

• Many doctors may be working within the context of accountable care organizations (ACOs) - in which doctors will be paid to care for large defined populations of Medicare patients and will be required to follow a series of complicated bureaucratic rules.
Tweet: Hospitals oppose Republican bill giving doctors 2-year reprieve from 27% cuts but which lowers hospital Medicare payments by $17 billion.

Tuesday, December 13, 2011

Power-worship blurs political judgment because it leads, almost unavoidably, to the belief that present trends will continue.

George Orwell (1903-1950), Raffles and Miss Blandish, (1944)

December 13, 2011 - These days news of the future of health care's big transformations are coming fast and furious.

Why? Because pressures to cut costs are transforming business models. It is becoming survival of the biggest- a contest between bigger and bigger power-mongers. WSJ’s Anna Mathews says the future of health care is “blurred” – in the sense hospitals, physicians, are consolidating into bigger and bigger amorphous blobs. So amorphous, it’s hard to tell who is running the show.

If you’re big, amorphous, and dominate a market, you’re harder to push around, even by Big Brother. After all, patients have to get their care somewhere, and if you’re the only game in town, where are patients going to go? And what can government do? If present trends toward consolidation continues, you tend to believe you will have the power to negotiate the best deals. In the end, I suppose it will come down to Trust vs. Anti-Trust, and to the question: will govenrment be able to slay the monstrosities it created?

Anna Mathews of the WSJ describes the power of consolidation in a December 12 Marketplace Section of the Journal in an article entited "The Future of U.S. Health Care," with a subtitle of "The Lines are Blurring Between Insurance Companies, Hospitals, and Other Health-Care Providers."

She points out that:

• the percentage of 800,000 doctors who own their own practices will drop from about 50% in 2000 to 33% in 2013;

• hospitals are “bulking up” by acquiring other hospitals, with the number of acquisition climbing from 35 in 2002 to 82 in 2011;

• accountable care organizations, made up health-care providers conjoined at the hip, are coordinating the care of defined groups of patients and sharing the savings - 15% of hospitals say they currently have an ACO in place, and that number may grow to 80% BY 2015.

• Insurers are buying health care providers at an accelerating rate.

-- On June 8, 2011, Wellpoint announced it would buy the CareMore Health Group for slightly less than $800 million;

--On August 31 the United Group’s Optum said it would buy Monarch HealthCare, a 2300 doctor association in California;

Monday, December 12, 2011

Preface: Anthony Regalado, business editor of the MIT Press’ Technology Review (http://www.technology review.com/business/39216) sent me the following article, which will appear in Technology Review today.

The author of the article is Eric J. Topol, Chief Academic Officer of Scripps health. It is an important contribution to the health care innovation debate. Topol is also author of The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health.
Medicine Needs Frugal Innovation, December 12, Technology Review

A low-cost pocket ultrasound device can see into the human heart. So why do so few doctors use it?

In the history of medical innovation, advances in technology have been inextricably linked to increases in cost. But we are at a unique moment in which the insular world of medicine is about to be penetrated by the remarkable digital infrastructure. Think about the cost of computing. Over the past two decades, cost has been relentlessly reduced while capacity and performance have dramatically increased. How and when can this trend reach the practice of medicine, where costs often go up with little real improvement?

Let's consider the icon of medicine—the stethoscope draped around the doctor's neck or in the pocket of a white coat. Invented by René Laënnec in 1816, the stethoscope didn't see routine use by the medical community for another 20 years. The lag in acceptance reflected the conservative nature of physicians, who objected to having to learn heart sounds and let an instrument get between their healing hands and the patient.

Now, nearly 200 years later, economic forces are greatly slowing the adoption of a powerful replacement for the stethoscope in cardiac medicine. Instead of listening to the heart of a patient, I can now watch it on a device no bigger than a cell phone—a high-resolution miniature ultrasound probe. In fact, in my clinic I have not used a stethoscope to examine a patient's heart for the past two years.

Why would I listen to the "lub-dub" of heart sounds when I can actually see everything relevant about the heart in real time? Exquisite ultrasound images of the heart muscle—showing its contraction, its thickness, the size of the chambers, the valves, the sac around the heart—can all be obtained within seconds as part of a routine physical examination. I can share and discuss the images with the patient as they are being acquired, put video recordings in the electronic medical record, and send them to the patient or referring physician. The up-front cost of the pocket ultrasound device is about $7,700, but there is no extra cost for an unlimited number of readings.

That makes these small devices a formidable challenge to business as usual in American health care. Each year in the United States more than 20 million echocardiograms (ultrasounds of the heart) are performed, and so are a similar number of abdominal and fetal ultrasound examinations. Each of these diagnostic procedures is done in a dedicated laboratory setting, either in the hospital or in a doctor's office, with expensive equipment—and a combined professional and technical charge of $1,000 to $2,000. The math is straightforward. If a pocket ultrasound device were incorporated into routine physical exams the same way we use a stethoscope, several billion dollars in unnecessary charges would be saved each year.

Therein lies the rub—and the explanation for why many low-cost innovations are being held back in medicine. Those savings would represent a critical hit to revenue for doctors and hospitals. It's not just that doctors, like those who refused to use the stethoscope, are intrinsically conservative. The American health-care model of billing "medicine by the yard" creates economic disincentives to cost-saving technology. In contrast, pocket high-resolution ultrasound has been rapidly adopted and hailed as a breakthrough in countries such as India, China, and Brazil.

This represents just a single, simple example of how frugal innovation—the idea of coupling engineering creativity with lower costs—could be achieved if patient care in the United States were not determined by reimbursement rules. We now have wireless sensors that can help us diagnose sleep apnea by capturing all the relevant data for sleep studies—respiratory rate, oxygen saturation of the blood. The data can easily be captured for less than $100, right in a patient's home. But instead, the medical community keeps using $3,000-per-night hospital sleep labs to make the diagnosis.

I believe a great inflection is coming in medicine: advances in technology will finally help us override the reimbursement issue and topple the economic models that physicians, insurers, and hospitals still cling to. This moment will arrive as medicine is opened to the digital infrastructure of mobile wireless devices, pervasive connectivity, ever-expanding bandwidth, cloud and supercomputing power, and the Internet.

Superimposed on these digital capabilities are the ones specific to health care—genomic sequencing, biosensors, advanced imaging, and health information systems. It will all lead to what I call "high-definition man": a panoramic, granular profile of an individual's molecular biology, physiology, and anatomy.

Medicine, in short, has the potential for better technology at a much lower price, but don't look to the medical profession, government, or the life-sciences industry to make the change on its own. I believe the change will come when consumers demand it. The Arab Spring and the Occupy Wall Street movement have shown the influence of social networks as a way to express citizens' demands. Don't be surprised if health care is occupied next.

Fitting and Proper Close

It is altogether fitting and proper that I close with this perverse verse.

The Health System, From Top-Down to Bottom-Up, As Seen Through Lens of Cultural Complexity

Substitle of Book, Obama, Doctors, and Health Reform, 2009

December 12, 2011 - One purpose of this blog, which now has 2064 entries over the last 5 years, is to illustrate the complexity of health reform.

Here I have chosen to show how doctors react to reform's complexity by showing what they are reading in the Medinnovation blog.

What follows are the top ten Medinnovation blogs read by doctors over the last 36 months.

As you read the title of these ten blogs, keep in mind that the Accountable Care Act, aka Obamacare, passed 20 months ago on March 23, 2010. One of these blogs, preceded the ACA, nine occurred after its passage.

1) Is Practice Fusion’s “Free” EHR for Real?

May 23, 2010, 2537 Hits

This is by far most visited blog, by a factor of 2.5:1. The goals of universal physician/hospital EHRs are to document, monitor, control, and decide how to pay for tens of billions of annual patient-doctor-hospital transactions through the miracle of Health Information Technologies.

Achieving these goals is powered by $27 billion federal dollars and complicated by 186 EHR companies vying for the business. Practice Fusion Inc has grown 7-fold to 130,000 physician-users over the last year by simplifying EHR installations, transactions, use, and price. Practice Fusion is just one of these EHR companies. Other EHR firms are also growing rapidly.

Doctors know EHRs are inevitable but are waiting to see how effortlessly, cheaply, effectively, and efficiently they can get on the right side of the Digital Divide without disrupting their practice or losing revenue while still qualifying “meaningful use” bonuses.

2) Interview, physician Shortage - Interview with Richard "Buz" Cooper, M.D., Professor of Medicine at the University of Pennsylvania

Jan 24, 2009,1,194 Hits

This is an interview with “Buz” Cooper, MD, U Penn professor of medicine, who predicted large doctor shortages long before anyone else. In the interview, he gives reasons for the shortage. Cooper says health reform is on a collision course with shortage of doctors. Contrary to popular belief,engendered by Dartmouth Institute that provider greed leads to regional differences in Medicare costs, Cooper believes highest costs occur among poorest patients, whose costs are high care because prevention,diagnosis, and treatment are often neglected until late in disease.

3) Primary Care Revolt: Replace the RUC

Apr 17, 2011, 1107 Hits

This is an under-the-radar account of a revolution going on out there. It is a revolt of primary care physicians against the AMA and CMS. It is a request for parity with specialists. It is a movement to replace how primary care practitioners are paid. The RUC, Reimbursement Update Committee, or the Relative Value Reimbursement Value Committee, is dominated by specialists. These specialists, say the Primaries, ovwerwhlmingly set Medicare fees for doctors. RUC is a creature of the AMA. CMS endorses its decisions over 90% of the time. Primary care societies claim RUC fee schedule favors specialists and says its list of members should be reconfigured to give primary care specialists more of a voice.

4) The Low Value of Primary Care Doctors in Eyes of Patients

Jul 1, 2010, 971 Hits

Sometimes it is painful to discuss the obvious, especially when the obvious goes against your grain. But here goes. Primary care is in a bad way. Only 2% of medical students are picking primary care specialties. The number of primary care doctors is dropping. And over 90% of costs stem from specialty care. Primary care disarray, unhappiness, and low morale comes from these obvious causes : low reimbursement, long work hours, and as Rodney Dangerfield, might say, “We get no respect.” This in face of the fact that policy types and payers, like IBM, are calling for a rejuvenation of primary care as the salvation of American medicine with its cost, coordination, care improvement, and efficiency problems.

5) The Future of Accountable Care Organizations

Jan 26, 2011, 607 Hits

This was an interview with Bill DeMarco, a health care consultant for more than 30 years and an advisor on Accountable Care Organizations (ACOs). The subject of Accountable Care Organizations (ACOs) accounted for only 10 pages of the 2700 page health reform bill. Yet ACOs were then the buzz, the rage, the hottest 3-letter acronym since sliced bread, and the most talked about subject in hospital board rooms, medical staff lounges, and the medical talk circuit, and consultant enclaves. I am cautiously pessimistic about the future of ACOs. My views on ACOs are available in an e-book , Pros and Cons of Accountable Care Organizations (www.practicesupport.com).

6) Comments on Yesterday’s Value (Outcomes/Cost) Blog

Dec 31, 2010, 474 Hits

I posted this blog on the value of measuring outcomes of various diseases based on cost. The Health Care Blog, probably the most widely read of blogs pertaining to health care policies, reran my piece. In my blog,I expressed skepticism about the practicality of value determinations based on outcome measurements on a broad scale across the medical care spectrum. I closed with these questions. Here are the comments from readers of The Health Care Blog.

I ended my blog with these questions.

1. Is overall health care value measurable?

2. Are the organizational, societal, and individual costs required to make this value measurement worth it?

3. Will the measurement of value unify ideological factions competing to advance the cause of health reform?

I had my doubts.

7) Why Doctors Don't Like Electronic Health Records

Oct 7, 2011, 455 Hits

On September 27, 2011, An article of mine appeared in the Technology Review, an MIT Press publication. The Health Care Blog, the most widely read health blog, reran it on October 9, and it immediately drew 26 responses.

The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical. In 2004, the Bush administration issued an executive order calling for a universal "interoperable health information" infrastructure and electronic health records for all Americans within 10 years.

And yet, in 2011, only a fraction of doctors use electronic patient records. There at least 10 good reasons doctors resist EHR use.

8)Health Reform: Look at Massachusetts First

May 2, 2011, 347 Hits

If you doubt the likely effects of health reform on health care, says Kevin Pho, MD, in its widely-read blog, Kevinmd.com, "Look at Massachusetts first." In its stab at universal coverage, now four years old, Massachusetts has seen these consequences: overcrowded ERs, longer waiting times to see doctors, more than 50% of primary care doctors closing practices to new patients, and the highest health care premiums in the nation.

So much for lowering health costs and expanding access. And all of this in state with more primary care physicians per capita than any other state, in a state with fewer uninsured than any other state, and in a state with an individual mandate and a health plan said to be a model for Obamacare.

These, of course, all factors in Mitt Romney's baggege as a Republican Presidental candiate. He must explain to conservatives and the public at large the rationale of his support for the individual mandate and why and how Romneycare differs from Obamacare, His answer is that ech state is entitled to its own brand of health care, and the people of Massachusetts like their plan by a 3:1 margin.

9) Accountable Care Organizations (ACOs): California or Bust.

Sept 16, 2010, 1 268 Hits

I am skeptical in this blog about the futue of ACOs.

Why was I skeptical?

I suppose one reason is that I have been down the road before as a founder of the Physician Hospital Care Organization, later the Integrated Care Organization, in the 1990s, both now defunct because of mutual physician-hospital distrust and conflicting competitive goals.

Secondly, California’s business and health care climate, politically and in health care, are not representative of the U.S. as a whole.

Thirdly, California is a budgetary basket case, with a budget deficit of $20 billion.

Fourthly, I am dubious of the Congressional Business Offices estimate that ACOs will save $4.9 billion over 10 years through a limited pilot program.

I may have been wrong, but, given the complexity of the final ACO rules, enthusiasticlly endorsed by CMS administration by CMS Administator Donal Berwick, before Republicans forced his resignation, and almost universal rejection by the hospital, physician, large health system communities, there was room for skepticism.

Why, if health care will be the next engine of growth and will consume ever more of the GDP, are doctors feeling so glum about the future? If you doubt how they feel, I invite you to read Health Reform and the Decline of Physician Private Practice (Merritt Hawkins. October 2010).

This feeling of dread is not new. In 1977, John Knowles, MD, a Massachusetts General internist who became the President of the Rockefeller Foundation, edited a book Doing Better and Feeling Worse: Health in the United States (W.W. Norton and Company).

The problem then, as now, was the system was doing better in improving health outcomes but doing worse in controlling costs, and many of the bad things, in both the economic and health realms, that happen to people were beyond the reach of medicine. The health system didn’t have all the answers.

To take a leading example, why can’t we contain demand and control health costs?

That, of course, is this year’s $2.7 trillion question - the estimated cost of the ACA from 2014 to 2024.

According to Regina Herzlinger, PhD, a tenured professor at Harvard Business School, the problem is we don’t let consumers, spend their own money. pick their own providers, drive the system.(Who Killed Health Care? America’s $2 Trillion Medical Problem – and the Consumer-Driven Cure (McGraw Hill Companies, 2007).

Dr. Herzlinger identifies the five “killers” of a consumer-driven system as:

1. Health insurers, who insure the death of cost control through their dysfunctional culture.

2. General hospitals, which kill cost-control through their building of centralized. Ever-expanding empires of care.

3. Employers, who doom consumerism because they generally give their employees the “choice” of only one plan.

4. The U.S. Congress, who spur cost growth through lavish entitlement program riddled with fraud, abuse, and overuse.

5. Academics who contribute to the death of consumerism because of their elitist, technocratic, superior attitudes.

“Sadly, “comments Herzlinger, “on the federal government level, representatives from Republicans and Democrats have quaffed deeply form the Beltway Kool-Aid well. Neither believes in the power of innovators and consumers to reshape markets. Neither is in the-small-is-beautiful camp. Both believe the more oversight of health care by the government and academies is the solution. Both believe that big-is-beautiful.”

She goes on, “The federal government has not only specified what should be measured but also the protocols that health care providers must follow. These monopolistic powers are cloaked in the pseudoscientific mantle of ‘evidence-based.” The title implies that the guidelines are shaped by intelligent saints devoid of a shred of self-interest or vanity, guided only by ‘evidence’”

Small wonder doctors are glum. Everyone else, other than themselves and their patients, think they know what is best about the practice of medicine and the health care business. The health reform law effectively squelches health savings accounts which encourage consumers to shop for what they consider to be the best deal and doctors to compete for the consumers’ dollar. Rules and regulations forbid doctors to creatively re-design their practices and repackage their services. Medicare laws prohibit patients and doctors from privately contracting with each other. Prices keeps rising as regulations keep growing.

Medicine, it seems, is too important to be left to doctors and consumers. Trust us, is the mantra. We’re from the government and other large institutions, and only we know what is good for you and yur health.

Tweet:Health reform is fiendishly complex. I offer these 10 most widely read Medinnovation blogs as evidence.

Sunday, December 11, 2011

Findability is a term for the ease with information contained on a website can be found, both from outside the website (using search ) and by users already on the website.

Wikipedia

December 11, 2011 - How hard is it to find something on health care reform or innovation on the Net?

It isn’t easy. Consider the number of results listed on Google for the Internet containing information on:

• Health care reform, 192 million

• Health care innovation, 5 million

• Health care findability, 800,000

Finding health reform Internet information is a little like finding a specific species of fish in the ocean (230,000 species at last count), or a needle in the Internet blog haystack (70 -100 million blogs and doubling every 6 months).

So how do you assess the “findability “ of your blog?

According to clickz.com, you follow this formula.

One point for 5 keywords for your blog on first result page for top five major search engine blogs: Google, Yahoo!. Bing, Ask, and Aol.Search.

If, for example, the keywords for medinnovation were:

• Medinnovation/ehrs,

• Medinnovation/ health reform,

• Medinnovation/health innovation,

• Medinnovation/physicians,

• Medinnovation/hospitals,

Medinnovation would have 237 points.

According to clickz.com, this would give Medinnovation a high rating.

Points Ratings

200+ Yes, Master!

100-199 Extraordinary

50-99 Target Zone

20-49 Good

0-19 Thank God,we found you!

Of course, by putting medinnovation in front of the subject matter of my blogs, I have stacked the odds in favor of finding my blog in the Internet haystack.

But so what? I only have one fish to fry, one fish in the Net, one fish in giant kettle of blogs, and one fish in the sea of the blogosphere.
In closing,

Friday, December 9, 2011

Edgeware is a thinking approach. This is not a program that you roll out in organizations with banners and coffee mugs. It is a new way of thinking and seeing the world – and, hence, a new way of working with real organizational and health care issues.

December 9, 2011- When I suggested a list of Christmas health care books in yesterday’s blog, I forgot to mention one of my favorites, Edgeware.

Edgeware is a 1998 paperback of 228 pages. You can buy it new on amazon for $26.49 and used for $4.69.

No, Edgeware is not about kitchen knifeware. It’s about health care’s complexity. It’s about taking and handling risks at care’s cutting edge.

Though Edgeware predated the health reform law by a dozen years, Edgeware's lessons apply to dealing with complexities at the edges of today’s health law.

Edgeware sets forth these principles.

• View your system through the lens of complexity – Health organizations are not like a machine or military organization. Reform is about dealing with complex, often fickle, human beings.

• Build a good-enough vision with minimum specifications - The government’s mistake is trying to implement a sweeping vision with maximum specifications. This mistake may bring down ACOs, EHRs, and the IPAB Indepedent Payment Advisory Board),

• When life is far from certain, lead from the edge. Balance, intuition, planning, and risk, giving honor to each. Government reform tries to lead from the center and gives no honor to what is intuitively wrong at the edge.

• Tune your place to the edge, fostering the “right” degree of information flow, diversities and differences, with power considerations inside and outside the organization – Don’t try to control everything, deal separately with contentious groups, seeking comfort with each.

• Uncover and work with paradox and tension – These are natural with sweeping reform. Live with them.

• Go for multiple actions at the edge- rather than being absolutely certain before you do anything. Uncertainty is the name of the reform game. Health care uncertainties are a big reasons businesses don't hire.

• Listen to the shadow system- gGossip, informal relationships, rumors, and hallway conversations – They are powerful and may dictate future actions.

• Grow complex systems by chunking – These systems emerge from links of simple systems that work well independently.

• Mix cooperation and competition - This will always be true with hospitals and physicians. You cannot force competiton. It doesn’t work.

Tweet:Health reform follows the principles of complexity science. Learn how to adapt to complexity by reading the book, Edgeware.

Thursday, December 8, 2011

December 8, 2011 - 'Tis the season to turn our thoughts to the poor, and what we can do for them, short of massive government welfare programs.

These thoughts on the poor have not escaped the attention of John Commins, an editor of HealthLeaders Media. He wrote a piece today called, “Primary Physicians Link Social Barriers to Poor Health." In it, he cited an online survey of 1,000 primary care physicians, including 310 pediatricians, on behalf of the Robert Wood Johnson Foundation.

The survey found that:

• 85% of physicians say unmet social needs are directly leading to worse health for all Americans.

• 85% of physicians say patients' social needs are as important to address as their medical conditions. This is especially true for physicians (or 95%) serving patients in low-income, urban communities.

• 76% of physicians want the healthcare system to cover the costs associated with connecting patients to services that meet their social needs if a physician deems it important for overall health.

• Only 20% of physicians feel confident or very confident in their ability to address their patients' unmet social needs.

• Physicians said that if they had the power to write prescriptions to address social needs(italics mine) these would represent 1 out of every 7 prescriptions they write— or an average of 26 additional prescriptions per week.

These findings will come as no surprise to the Physicians Foundation, a charitable 501C3 organization representing at least 500,000 physicians in state medical societies.

On May 13, 2011, I wrote the following blog, which I reprint in full, on a $1 million grant to Health Leaders, Inc, addressing to the very needs of the poor the survey describes, especially the bit about what physicians would do if they had the power “to write prescriptions to address social needs.”

In 22 pediatric and prenatal clinics, newborn nurseries, emergency rooms, and community health centers in six cities across the U.S., physicians now have that power – a power that is likely to spread as Health Leads expands to other cities across the land, thanks to generosity of the Physicians Foundation and the physicians it represents.

May 11, 2011 Medinnovation Blog

The Physicians Foundation Awards $1 Million Grant to Health Leads

Yesterday the Physicians Foundation, a charitable organization representing physicians in state medical societies nationwide, put its money where its heart is.

The Foundation awarded a $1 million grant to Health Leads, a Boston non-profit to help it expand from its current base of six cities to other locales across the land.

The Physician Foundation-Health Leads collaboration is a natural partnership. Both the Physicians Foundation and Health Leads are organizations who think “outside the box” to help vulnerable citizens find resources outside the mainstream of care.

Physicians often find themselves trapped in a box, unable to help patients find food for their stomachs, heat for their homes, transport to medical facilities, jobs to supply the money to pay for care, decent homes in safe neighborhoods. These basics are simply beyond the reach of the current health system or the current reforms designed to improve care.

Health Leads works in 22 pediatric and prenatal clinics, newborn nurseries, emergency rooms, and community health centers in six cities across the U.S. Last year, Health Leads trained and deployed 660 college volunteers to connect nearly 6,000 low-income patients and their families to the resources they need to be healthy. By providing a transformative experience for hundreds of college volunteers, Health Leads is producing a pipeline of new leaders who will have both the conviction and the skills to transform health care from the bottom-up.

How does Health Leads make this transformation possible ?

• One, by giving doctors the power to “prescribe” food, shelter, job training, and transportation by writing prescriptions to find these resources.

• Two, by recruiting college volunteers to serve at Health Desks in various health care settings to direct patients and families to community resources, in the process serving as a training ground for health careers and as a sort of domestic Peace Corps.

In the hospitals and health centers where Health Leads operates, doctors can “prescribe” food, housing, or other critical resources—just as they would medication. Patients take their prescriptions to the clinic waiting room, where Health Leads’ college volunteers are ready to connect them to these resources. Nearly 60 percent of Health Leads patients secure at least one critical resource – receive food, get their heat turned back on, find a job – within 90 days of getting their “prescription.” All patients receive ongoing follow-up until their needs are met.

“As we continue to identify new ways to enhance healthcare delivery, we are extremely proud to fund the ongoing efforts of Health Leads,” said Dr. Walker Ray, Vice President of The Physicians Foundation and Chair of the Research Committee. “In a system that is massively overburdened by strained resources, innovative models that foster collaboration between college volunteers and physicians can have real impact on our nation’s healthcare.”

The Physicians Foundation’s funding will help Health Leads expand its operational capabilities, allowing the organization to serve significantly more patients. By developing an information technology infrastructure to enhance tracking of patient outcomes and by hiring additional program managers and staff, Health Leads will be able to deepen engagement with physicians and clinic partners.

“Health Leads is grateful for the assistance of The Physicians Foundation in helping us to build the capacity we need to scale our program model over the next four years. Since we received their funding, we have been able to serve more than 2,600 patients, putting us on track for an increase of more than 60 percent over last year,” said Rebecca Onie, Co-founder and Chief Executive Officer of Health Leads.

“We have also launched discussions to build an evaluation partnership with the Mayo Clinic Center and rolled out a new client database to all of our sites that will enable us to better track and report client outcomes. The Foundation's support has been invaluable in helping us make significant progress on these strategic goals."

Tweet: The Physicians Foundation, a doctor organization, has awarded a $1 million to Health Leads, to help patients find food, housing, & jobs.

The Health Reform Maze

Buy the Book

Book Description: In this first book in a series of four, Richard L. Reece, MD. provides a unique view of the roll out, and run up, of the Affordable Care Act. Reece shows in this book the progress and facets of ObamaCare's marketers and messengers, as the day approached for the launch of health insurance exchanges - the single most public and problematic portion of the new law. This is a must read for anyone who wants to chronicle this attempt to organize more than one-sixth of the U.S. economy by adding layers of federal government control and regulations.

Reece has been writing about U.S. health care for more than 45 years. His knowledge and experience, added to his keen intellect and gift of subtle humor, make this book a valuable part of anyone's collection.